the aaha diabetes guidelines: update on diabetes in dogs...
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AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
1
The AAHA Diabetes Guidelines:
Update on Diabetes in Dogs and Cats
November 30, 2010
By
Debra L. Zoran, DVM, PhD, DACVIM-SAIM
AAHA gratefully acknowledges
Intervet/Schering-Plough Animal Health
for their sponsorship of this web conference.
Questions to Consider:
What are the major risk factors for diabetes in cats and dogs?
How is feline diabetes different from canine?
How is dietary therapy of cats different from dogs?
What is a major goal of treatment?
What insulins are best for dogs? Which ones are best for cats?
What are the best ways to monitor therapy?
What are the key differences in monitoring cats?
What is Diabetes Mellitus?
“Starvation in the face of plenty” or “sweet urine” – due to the lack of insulin (dogs) or
insulin effectiveness (cats)
AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
2
Canine Diabetes Mellitus
Type I or IDDM >50% have autoantibodies
Most like LADA in humans
Other specific types 28% have chronic pancreatitis
Diestrus or progesterone induced in intact females
Type II diabetes in dogs is rare
Rand et al 2004
Feline Diabetes Mellitus
85-90% of cats are type II diabetics Insulin resistance due to obesity or drugs
Impaired insulin secretion
Other causes Chronic pancreatitis
Islet amyloidosis
Fleeman et al, 2004
Rand et al, 2008
Obesity is the Most Important Risk
Factor for Feline Diabetes
AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
3
What Are the Causes Insulin
Resistance in Cats?
Hormonal Obesity, acromegaly, hyperthyroidism,
hyperadrenocorticism
Infection related Periodontal disease, UTI
Drug related Steroids, megesterol (Ovaban), somogyi
effect (chronic insulin overdose)
Breeds With Increased Risk
Known genetic risk Keeshonds
Australian terriers
Cairn terriers
Miniature Pinschers
Burmese (cats)
Frequently affected (suspect genetic predisposition)
Poodles
Dachshunds
Miniature Schnauzers
Beagles
Domestic shorthair cats
Breeds with Low Risk of Diabetes
Cocker Spaniels
German Shepherds
Collies
Pekingese
Rottweilers
Boxers
Most purebred cats
AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
4
Why Do Dogs With Diabetes
Require Insulin and Cats May Not?
What is a Typical Diabetic?
Dogs: Spayed female,
middle aged, small
breeds, thin
Cats: Male, neutered,
indoor/inactive, middle
aged to older, obese
Typical History?
Polyuria/polydipsia/polyphagia
Weight loss
Cats are obese (but are losing weight), dogs are thin
Normal activity/attitude (except ketoacidotic diabetics - DKA)
May present for evaluation of urinary problem (e.g. hematuria, urinating in house)
AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
5
Differences in Clinical Disease
of Dogs vs Cats
Dogs are more likely to develop cataracts
Peripheral neuropathies are more likely to develop
in cats
How Do We Make a Diagnosis of
Diabetes in the Dog?
How is diagnosis of diabetes in cats
different?
A Cat Presents to Your Clinic and
Has a Glucose of 185, What Are the
Possible Reasons?
Stress hyperglycemia
Sub-clinical diabetes
AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
6
What are the Causes of Persistent
Hyperglycemia in Cats?
Insulin available but target organs unresponsive
(insulin resistance)
Stress hyperglycemia
High carbohydrate diets (especially highly
digestible carbs) can cause prolonged post -
prandial hyperglycemia (Cave et al 2006)
No insulin produced (beta cell down-regulation
or loss/ destruction of beta cells)
Subclinical vs Clinical Diabetes
Cats and dogs in early stage of developing diabetes
May appear healthy, have a stable weight (cats are
often obese)
Must distinguish stress hyperglycemia from other
causes in cats, as persistent hyperglycemia
causes hyperinsulinemia (the first step in the
process of becoming a Type II diabetic)
Lab Evaluation of Diabetics
CBC, Chemistry Panel Non-specific CBC: mild leukocytosis
Hyperglycemia, increased SAP/ALT, hypercholesterolemia
Liver function studies not needed unless low albumin or very high ALT/GGT/SAP
Fatty liver syndrome common
Urinalysis – essential Glucosuria, bacteriuria (culture)
Other lab tests: T4, PLI/TLI, cobalamin (cats)
Imaging, Blood pressure (cats)
AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
7
Once a Diagnosis Is Made, What
Are the Two Most Important
Components of Therapy?
Dietary management
Insulin therapy
Goals of Managing A Diabetic Dog
Reduce or control clinical signs PU/PD/PP, weight gain
Prevent complications of disease Cataracts, DKA, neuropathies
Maintain quality of life for both dog and owner
Major Difference in Goals for Cats
Goals are similar for quality of life, prevention of
complications and reduction of signs
Type II diabetes in cats is a reversible condition
with the proper combination of diet, insulin
therapy and monitoring – so….the most
important difference is the goal to achieve
clinical remission in cats
AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
8
Dietary Therapy in Dogs
Normalize body weight
Feed palatable food so that intake is predictable
Maintain consistency in caloric content and timing of meals
Minimize post-prandial blood glucose concentrations
Goals of Dietary Therapy in Diabetic
Cats: Same but Different Approach
Normalize body weight – essential to
correction of insulin resistance
Maintain consistency in caloric content of
meals but increase frequency
Minimize postprandial blood glucose
Reverse to pre-clinical state
What Is the Best Way to Minimize
Post-Prandial Hyperglycemia in the
Cat?
Feed a high protein (>45%), low
carbohydrate diet
AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
9
Timed Feeders: Control Intake but
Decrease Risk of Hypoglycemia with
Meals Every Six Hours
What Is the Best Diet Choice in
Canine Diabetics?
A diet that the dog will consistently eat,
that normalizes body weight, is not
high fat (pancreatitis), does not have
high sugar levels (soft moist), and has
modest amounts of mixed fiber
Starting Insulin Therapy
First choose an insulin Cats: Glargine, PZI
Dogs: NPH, Porcine Zinc
(Lente) insulin suspension
Select a starting dose:
BE CONSERVATIVE!! Cats 1 U/cat (1/4 U/kg lean)
Dogs: 1/2 U/kg q12h
AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
10
Choosing an Insulin
Intermediate acting insulins (human recombinant NPH, e.g. Humulin or Novolin N, or porcine zinc (lente) insulin suspension, e.g. Vetsulin if it becomes available) give acceptable results in dogs given twice daily
Long acting insulins (Glargine or PZI) are better for cats and more likely to achieve remission – intermediate acting insulin can be used but often are too short acting and more likely to cause hypoglycemia
Starting with BID administration improves remission
Keys to Insulin Therapy in Dogs
There are no insulins for dogs that are consistently effective for once/day dosing
Dogs require BID insulin dosing
Consistent diet, timing of insulin, and exercise are keys to effective management
Control common causes of insulin ineffectiveness: UTI, thyroid or adrenal disease, dental/skin/ear infections
Why Glargine in Cats?
Insulin analogues (not recombinant)
Absorption is slow because it forms hexamers in
the sub-Q that are pH dependent that must be
broken down to release the insulin
Slow absorption and effect reduce the risk of
hypoglycemic crisis in cats and increase the
control of glucose over time (better chance for
remission) – also require less frequent
monitoring of BG
AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
11
What Is the MOST Serious Adverse
Effect of Insulin Therapy?
Hypoglycemia
Why is this so difficult to detect in cats?
Monitoring Insulin Therapy:
The Owner’s Role
Monitor clinical signs
Monitor urine glucose Negative = hypoglycemia….
Positive or ketones – need to reassess
Home monitoring with glucometers Mid-day blood glucose – essential for
cats that have severe stress hyperglycemia or travel issues
Excellent way to monitor glargine due to long action, lack of short term nadir
Monitoring Options
Use a monitor the owner is comfortable with
Animal vs human monitors: pros and cons
AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
12
Home Monitoring is Ideal in Cats
and Easy to Learn
Monitoring the Response to Insulin:
The Veterinarian’s Part…
Overall health maintenance
Fructosamine Gives “snapshot” of 21 day period – but
doesn’t replace curve in dogs or when
diagnosing insulin issues
Blood glucose curves (dogs) Day-to-day variation is enormous
Use with Hx, PE, and body wt changes
Use with caution in cats – best if home
Evaluating the Blood Glucose Curve
AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
13
What is Happening Here?
What is Happening Here?
0
100
200
300
400
500
Key Management Points
Be cautious with adjustments until the owner and
pet have established their routine
Tailor the monitoring to the dog or cat and owner but
encourage home monitoring
Treat the pet, not the lab results – especially in
assessment of curves in cats done in the clinic
Cats are prone to development of hypoglycemia due
to diabetic remission so insulin therapy and
monitoring should be planned with this in mind
AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
14
Summary Points
Minimize complicating factors
Reduce owner and pet stress
Don’t seek perfection with glucose levels or
curves
Seek quality of life – reduce PU/PD and
PP, normalize body weight
In cats, use diet (and insulin) to achieve
clinical remission
Questions?
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AAHA National Staff Meeting Web
Conference - The AAHA Diabetes
Guidelines: Update on Diabetes in Dogs
and Cats
November 30, 2010
15
Questions to the Speakers
Please email your questions to [email protected] by Tuesday, December 7, 2010.
Dr. Zoran will provide written responses to all of the questions and they will be posted on AAHA’s website by Sunday, December 19, 2010.
AAHA gratefully acknowledges
Intervet/Schering-Plough Animal Health
for their sponsorship of this web conference.